Safety of Flexible Sigmoidoscopy in Pregnant Patients with Known or Suspected Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Lower gastrointestinal endoscopy is crucial in the diagnosis and staging of inflammatory bowel disease (IBD). However, there are limited safety data in pregnant populations, resulting in conservative society guidelines and practice patterns favoring diagnostic delay. We studied whether performance of flexible sigmoidoscopy is associated with adverse events in pregnant patients with known or suspected IBD. METHODS: A retrospective cohort study was conducted at the University of California San Francisco (UCSF) between April 2008 and April 2019. Female patients aged between 18 and 48 years who were pregnant at the time of endoscopy were identified. All patient records were reviewed to determine disease, pregnancy outcomes, and lifestyle factors. Two independent reviewers performed the data abstraction. Adverse events were assessed for temporal relation with endoscopy. RESULTS: We report the outcomes of 48 pregnant patients across all trimesters who underwent lower endoscopy for suspected or established IBD. There were no hospitalizations or adverse obstetric events temporally associated with sigmoidoscopy. 78% (38/50) of lower endoscopies performed in the patients resulted in a change in treatment following sigmoidoscopy. 12% (5/43) of the lower endoscopies performed in patients with known IBD showed no endoscopic evidence of disease activity despite symptoms. CONCLUSIONS: Lower endoscopy in the pregnant patient with known or suspected IBD is low risk and affects therapeutic decision making. It should not be delayed in patients with appropriate indications.

Training and assessment in flexible sigmoidoscopy: using a novel direct observation of procedural skills (DOPS) assessment tool.

BACKGROUND AND AIMS: Data supporting milestone development during flexible sigmoidoscopy (FS) training are lacking. We aimed to present validity evidence for our formative direct observation of procedural skills (DOPS) assessment in FS, and use DOPS to establish competency benchmarks and define learning curves for a national training cohort. METHODS: This prospective UK-wide (211 centres) study included all FS formative DOPS assessments submitted to the national e-portfolio. Reliability was estimated from generalisability theory analysis. Item and global DOPS scores were correlated with lifetime procedure count to study learning curves, with competency benchmarks defined using contrasting groups analysis. Multivariable binary logistic regression was performed to identify independent predictors of DOPS competence. RESULTS: This analysis included 3,616 DOPS submitted for 468 trainees. From generalisability analysis, sources of overall competency score variance included: trainee ability (27%), assessor stringency (15%), assessor subjectivity attributable to the trainee (18%) and case-to-case variation (40%), which enabled the modelling of reliability estimates. The competency benchmark (mean DOPS score: 3.84) was achieved after 150-174 procedures. Across the cohort, competency development occurred in the order of: pre-procedural (50-74), non-technical (75-149), technical (125-174) and post-procedural (175-199) skills. Lifetime procedural count (p<0.001), case difficulty (p<0.001), and lifetime formative DOPS count (p=0.001) were independently associated with DOPS competence, but not trainee or assessor specialty. CONCLUSION: Sigmoidoscopy DOPS can provide valid and reliable assessments of competency during training and can be used to chart competency development. Contrary to earlier studies, based on destination-orientated endpoints, overall competency in sigmoidoscopy was attained after 150 lifetime procedures.

A novel endoscopic treatment for anastomotic leakage post anterior resection: Padlock over the scope clip.

BACKGROUND: Anastomotic dehisense is a serious complication of anterior resections. We have had success in our centre utilising Endosponge therapy to salvage anastomotic leaks but this requires multiple endoscopic sessions and can take around 6 weeks to heal in some cases. This can delay further management such as chemotherapy. AIM: We describe the novel use of Padlock over the scope clips to manage patients with anastomotic dehisense post anterior resection. METHOD: Padlock over the scope clips were used to manage three patients who presented with anastomotic breakdown post laparoscopic anterior resection between February 2016 and July 2017. RESULTS: These patients were initially managed conservatively with IV antibiotics and fluids. One case was first managed with Endosponge treatment before a Padlock clip was utilised to bridge a narrow defect. The other cases were managed initially with CT-guided percutaneous drains before clip deployment. Patients were followed up with regular clinic and sigmoidoscopies. All three cases demonstrated anastomotic salvage and satisfactory healing. This allowed the patients to be fit for their chemotherapy in less than 4 weeks from presentation. There were no complications from utilising the Padlock clips in these cases. CONCLUSION: Utilising over the scope endoclips previously has been thought to be limited by the size of defect. Our experience details novel combination techniques that allow for quick resolution and the expeditious commencement of further management such as chemotherapy. These clips also proved to be cost-effective in our centre, utilising less inpatient and outpatient resources than alternative management plans.

Early detection versus primary prevention in the PLCO flexible sigmoidoscopy screening trial: Which has the greatest impact on mortality?

BACKGROUND: Screening for colorectal cancer (CRC) with flexible sigmoidoscopy (FS) has been shown to reduce CRC mortality. The current study examined whether the observed mortality reduction was due primarily to the prevention of incident CRC via removal of adenomatous polyps or to the early detection of cancer and improved survival. METHODS: The Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial randomized 154,900 men and women aged 55 to 74 years. Individuals underwent FS screening at baseline and at 3 or 5 years versus usual care. CRC-specific survival was analyzed using Kaplan-Meier curves and proportional hazards modeling. The authors estimated the percentage of CRC deaths averted by early detection versus primary prevention using a model that applied intervention arm survival rates to CRC cases in the usual-care arm and vice versa. RESULTS: A total of 1008 cases of CRC in the intervention arm and 1291 cases of CRC in the usual-care arm were observed. Through 13 years of follow-up, there was no significant difference noted between the trial arms with regard to CRC-specific survival for all CRC (68% in the intervention arm vs 65% in the usual-care arm; P =.16) or proximal CRC (68% vs 62%, respectively; P = .11) cases; however, survival in distal CRC cases was found to be higher in the intervention arm compared with the usual-care arm (77% vs 66%; P<.0001). Within each arm, symptom-detected cases had significantly worse survival compared with screen-detected cases. Overall, approximately 29% to 35% of averted CRC deaths were estimated to be due to early detection and 65% to 71% were estimated to be due to primary prevention. CONCLUSIONS: CRC-specific survival was similar across arms in the PLCO trial, suggesting a limited role for early detection in preventing CRC deaths. Modeling suggested that approximately two-thirds of avoided deaths were due to primary prevention. Future CRC screening guidelines should emphasize primary prevention via the identification and removal of precursor lesions. Cancer 2017;123:4815-22. © 2017 American Cancer Society.

Persistent residual contamination in endoscope channels; a fluorescence epimicroscopy study.

BACKGROUND AND STUDY AIMS: The increasing demand for endoscopic procedures poses new contamination challenges, given developing antimicrobial resistance worldwide and potential viral or prion diseases in populations at risk. We examined working channels from reusable luminal endoscopes used in recent years. METHODS: Very sensitive fluorescence epimicroscopy was used to examine working channels from 6 decommissioned and 6 factory-new channels, as received, or following spiking and washing in the laboratory. RESULTS: After a single contamination and wash test cycle, new channels retained approximately 75 pg/mm(2) of proteins; through 7 subsequent cycles residual proteins fluctuated between 25 and 75 pg/mm(2). Decommissioned channels harbored 1 - 4 µg of proteins each, except in one gastroscope (33 µg), including up to 2 % amyloid proteins except in one gastroscope and one sigmoidoscope (with over 80 %); lumens showed wearing with established abraded biofilms in 3 cases. After spiking with scrapie-infected blood components and washing, residual protein levels in new channels varied following standard (17.23 pg/mm(2)), duplicated (2.39 pg/mm(2)) or extended (11.3 pg/mm(2)) washing; no changes were measured among the long-established contamination in old channels. CONCLUSIONS: Our observations suggest that wear effects in endoscope lumens may contribute to the adsorption of proteins, thus facilitating retention and survival of bacteria. As demonstrated by recent outbreaks worldwide despite recommended reprocessing, the development of antimicrobial-resistant bacterial strains, and the estimated prevalence of variant Creutzfeldt-Jakob disease (vCJD) in the UK particularly, combined with increasing demand for endoscopic procedures, call for sustained precautions and improved methods for the reprocessing of nonautoclavable, reusable surgical instruments.

Straight to flexible sigmoidoscopy: rationalization of 2-week wait referrals in suspected colorectal cancer.

AIM: The 2-week wait pathway was designed to decrease the time from presentation to primary care of patients with 'red flag' symptoms of suspected cancer for review by a specialist for the diagnosis or exclusion of cancer. In our tertiary referral centre we have found that 968 colonoscopies per year are required to satisfy the demand for the 2-week wait, leading to limited colonoscopy availability for other services. We sought to determine the yield of colorectal cancer found at colonoscopy referred via the 2-week wait and referenced to the original red flag symptoms. This was in order to select the most efficacious alternative primary investigation based upon presenting symptoms. METHOD: Electronic records were retrospectively analysed. All patients who went through the 2-week wait for suspicion of colorectal cancer in 2013 and were found to have colorectal cancer on colonoscopy were included. Patients not undergoing colonoscopy as the first investigation were excluded. The splenic flexure was deemed to be within the range of a flexible sigmoidoscope. RESULTS: In all, 2950 referrals were made. 968 colonoscopies were performed as the primary investigation of which 35 were found to have colorectal cancer. No patients referred with rectal bleeding and another symptom had a tumour more proximal to the range of flexible sigmoidoscopy. 80% of tumours proximal to the splenic flexure were suitable for CT diagnosis alone. CONCLUSION: Our data support the use of flexible sigmoidoscopy alone as an initial investigation for patients presenting with rectal bleeding with or without additional colorectal symptoms. Patients with anaemia (without bleeding) or change in bowel habit (without bleeding) may be investigated with CT colonography alone; colonoscopy may then be used selectively prior to surgery.

Reduced incidence and mortality from colorectal cancer with flexible-sigmoidoscopy screening: a meta-analysis.

AIM: To conduct a systematic review and meta-analysis of published population-based randomized controlled trials (RCTs). METHODS: RCTs evaluating the difference in mortality and incidence of colorectal cancer (CRC) between a screening flexible sigmoidoscopy (FS) group and control group (not assigned to screening FS) with a minimum 5 years median follow-up were identified by a search of MEDLINE and EMBASE databases and the Cochrane Central Register for Controlled Trials through August 2013. Random effects model was used for meta-analysis. RESULTS: Four RCTs with a total of 165659 patients in the FS group and 249707 patients in the control group were included in meta-analysis. Intention-to-treat analysis showed that there was a 22% risk reduction in total incidence of CRC (RR = 0.78, 95%CI: 0.74-0.83), 31% in distal CRC incidence (RR = 0.69, 95%CI: 0.63-0.75), and 9% in proximal CRC incidence (RR = 0.91, 95%CI: 0.83-0.99). Those who underwent screening FS were 18% less likely to be diagnosed with advanced CRC (OR = 0.82, 95%CI: 0.71-0.94). There was a 28% risk reduction in overall CRC mortality (RR = 0.72, 95%CI: 0.65-0.80) and 43% in distal CRC mortality (RR = 0.57, 95%CI: 0.45-0.72). CONCLUSION: This meta-analysis suggests that screening FS can reduce the incidence of proximal and distal CRC and mortality from distal CRC along with reduction in diagnosis of advanced CRC.

Sangrado digestivo bajo en pacientes menores de 50 años y la necesidad de colonoscopía completa / Bleeding lower digestive in patients less than 50 years and the need for complete colonoscopy

Objetivos: evaluar la proporción de lesiones que estuvieron al alcance del proctosigmoidoscopio flexible (60 cm) en pacientes sometidos a colonoscopia completa por sangrado digestivo bajo. Métodos: Se realizo una búsqueda de todos los pacientes menores de 50 años sometidos a colonoscopia completa por sangrado digestivo bajo sin signos de alarma, información recogida de los informes colonoscópicos del servicio de Gastroenterología de un Hospital Peruano desde enero 2009 a Diciembre 2011. Criterios Inclusión: hombres y mujeres menores de 50 años Indicación: Hemorragia digestiva baja, sangrado digestivo bajo, rectorragia, Sangre visible o hematoquezia, Colonoscopia que alcance ciego. Criterios Exclusión: Colonoscopia incompleta, otra indicación que no sea rectorragia, hematoquezia, sangre visible, sangrado digestivo bajo, Hemorragia digestiva baja; Antecedente de Neoplasia, antecedente familiar, anemia, baja de peso. Resultados: 98 por ciento de las lesiones estuvieron al alcance del proctosigmoidoscopio flexible, 2 por ciento estuvo distal al alcance del mismo y fueron úlceras en ciego, 100 por ciento de lesiones malignas estuvieron en recto que representa 3 por ciento de lesiones en este estudio. Conclusión: La gran mayoría de lesiones causantes de sangrado digestivo bajo en menores de 50 años se encuentran al alcance del proctosigmoidoscopio, también el 100 por ciento de lesiones malignas.

Aims: to evaluate the proportion of lesions beyond the reach of the flexible sigmoidoscope in patients younger than 50 years and without alarm features with lower gastrointestinal bleeding and a full colonoscopy. Methods: A search of all total colonoscopies performed in a Peruvian Hospital between January 2009 and December 2011, in patients younger than 50 years, with a history of LGIB and no alarm features was done. Inclusion Criteria: patients younger than 50 years, Indication LGIB, rectal bleeding, hematochezia, Colonoscopies must reach cecum. Exclusion Criteria: incomplete colonoscopies, another indication than LGIB, rectal bleeding, hematochezia. Anemia, history of neoplasia, family history, weight loss. Results 98 per cent of all the endoscopic findings was within the reach of sigmoidoscope, 2 per cent was distal of reach and was cecum ulcers, 100 per cent of malignant neoplastic was in the rectum and was 3 per cent of all endoscopic findings. Conclusions: Most of the endoscopic findings in patients younger than 50 years with lower gastrointestinal was within the reach of sigmoidoscope, 100 per cent of malignant neoplastic was too within the reach of sigmoidoscope.

A novel adaptor converts a laparoscope into a high-definition rigid sigmoidoscope.

The rigid sigmoidoscope is an important tool in a surgeon's armamentarium, yet it has remained essentially unchanged despite poor imaging and the inability to project or record the images. Herein we report our initial experience with a novel introducer built from readily available operating room supplies and designed to convert any standard laparoscope into a high-definition rigid sigmoidoscope.

Initial experience of single-port laparoscopic surgery for sigmoid colon cancer.

BACKGROUND: Single-port laparoscopic surgery has attracted attention in the field of minimally invasive colorectal surgery. We hypothesized that an experienced laparoscopic surgeon could perform single-port surgery for colon cancer eligible for conventional laparoscopic anterior resection. Our aim was to analyze our initial experience and immediate surgical outcomes of single-port anterior resection. METHODS: A total of 37 consecutive patients with presumed sigmoid colonic cancer underwent single-port anterior resection with standard laparoscopic instruments between May 2009 and June 2010. Each operation was performed by one of two experienced colorectal surgeons. A cohort of patients who had undergone conventional laparoscopic surgery (CLS) for the same duration a year earlier (August 2007 to September 2008) was used as a historical control. Patient demographics and perioperative outcomes were analyzed and compared with those of CLS. RESULTS: There were no significant differences in mean estimated blood loss, mean length of the resection margin, or morbidity between the two groups, but operative time for the single-port group was significantly shorter (118 ± 41 vs. 140 ± 42 min; p = 0.017). Single-port laparoscopic surgery was successfully performed in 78.4% (29/37) of the patients treated in 2010, and CLS was successfully completed in all of the patients treated the previous year (p = 0.000). The main causes of single-port surgery failure were adhesion and tumor location. CONCLUSIONS: Single-port anterior resection is a feasible and safe procedure with immediate outcomes comparable to those of conventional laparoscopy. Further studies are required to determine the feasibility of single-port surgery for colonic tumors outside the sigmoid colon and the long-term outcome.

Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy.

BACKGROUND: The benefits of endoscopic testing for colorectal-cancer screening are uncertain. We evaluated the effect of screening with flexible sigmoidoscopy on colorectal-cancer incidence and mortality. METHODS: From 1993 through 2001, we randomly assigned 154,900 men and women 55 to 74 years of age either to screening with flexible sigmoidoscopy, with a repeat screening at 3 or 5 years, or to usual care. Cases of colorectal cancer and deaths from the disease were ascertained. RESULTS: Of the 77,445 participants randomly assigned to screening (intervention group), 83.5% underwent baseline flexible sigmoidoscopy and 54.0% were screened at 3 or 5 years. The incidence of colorectal cancer after a median follow-up of 11.9 years was 11.9 cases per 10,000 person-years in the intervention group (1012 cases), as compared with 15.2 cases per 10,000 person-years in the usual-care group (1287 cases), which represents a 21% reduction (relative risk, 0.79; 95% confidence interval [CI], 0.72 to 0.85; P<0.001). Significant reductions were observed in the incidence of both distal colorectal cancer (479 cases in the intervention group vs. 669 cases in the usual-care group; relative risk, 0.71; 95% CI, 0.64 to 0.80; P<0.001) and proximal colorectal cancer (512 cases vs. 595 cases; relative risk, 0.86; 95% CI, 0.76 to 0.97; P=0.01). There were 2.9 deaths from colorectal cancer per 10,000 person-years in the intervention group (252 deaths), as compared with 3.9 per 10,000 person-years in the usual-care group (341 deaths), which represents a 26% reduction (relative risk, 0.74; 95% CI, 0.63 to 0.87; P<0.001). Mortality from distal colorectal cancer was reduced by 50% (87 deaths in the intervention group vs. 175 in the usual-care group; relative risk, 0.50; 95% CI, 0.38 to 0.64; P<0.001); mortality from proximal colorectal cancer was unaffected (143 and 147 deaths, respectively; relative risk, 0.97; 95% CI, 0.77 to 1.22; P=0.81). CONCLUSIONS: Screening with flexible sigmoidoscopy was associated with a significant decrease in colorectal-cancer incidence (in both the distal and proximal colon) and mortality (distal colon only). (Funded by the National Cancer Institute; PLCO ClinicalTrials.gov number, NCT00002540.).

The Hammersmith colorectal foot pedal.

AIM: This technical note describes use of a footpedal to switch on a rigid sigmoidoscope/proctoscope, demonstrating increased speed and efficiency of proctoscopy examination. METHOD: Use of a footpedal to control the light source of a rigid sigmoidoscope/proctoscope, enabling the user to switch the light source on and off with their foot, rather then at the wall, switch, leaving hands free. RESULTS: Benefits include increased efficiency and speed of examination with reduced time on the couch for the patient and reduced risk of the halogen lighting bulb being left switched on, thus prolonging the life of the equipment. CONCLUSION: Although we do not claim originality for its use we have found it particularly helpful and believe that its use should be more widely publicised.

Adequacy of flexible sigmoidoscopy with biopsy for diarrhea in patients under age 50 without features of proximal disease.

BACKGROUND: The optimal endoscopic investigation of diarrhea in patients under age 50 without specific features of right-sided colonic/ileal disease is inadequately defined. OBJECTIVE: To assess the potential additional yield of colonoscopy over flexible sigmoidoscopy (FS) in this group. DESIGN: Retrospective cohort study. SETTING: Two teaching hospital endoscopy units. PATIENTS: This study involved all patients under age 50 who had a colonoscopy between 1997 and 2007 to investigate diarrhea, without high-risk features of right-sided colonic/ileal disease, inflammatory bowel disease (IBD), or rectal bleeding. INTERVENTION: Colonoscopy and biopsy. MAIN OUTCOME MEASUREMENTS: Diagnostic yield of colonoscopy over FS with biopsy. RESULTS: Colonoscopic appearances were abnormal in 126 of 625 eligible patients (20%); 72% of abnormalities were within reach of FS. The most common endoscopic abnormality was suspected inflammation in 60 patients (10% overall), reportedly confined to the proximal colon or ileum in 22 patients (37% of this group). Histology from areas of suspected inflammation revealed features of IBD in 68% of patients, but results were normal in the remainder. In the 22 patients with suspected isolated proximal disease, 8 patients (36%) had normal histology results, and a further 6 had left-side colon biopsies demonstrating IBD. In patients with macroscopically normal colons, histological evidence of IBD or microscopic colitis occurred in 14 and 12 patients, respectively, with changes in the left side of the colon in 93% of patients. In this patient group, 85% of IBD or microscopic colitis could have been detected by FS and biopsy. The negative predictive value of FS with biopsy was 98% for IBD and 99% for microscopic colitis. LIMITATIONS: Retrospective study. CONCLUSION: FS is adequate for the investigation of diarrhea in patients under age 50 who lack other features, but its yield depends on biopsy of the left side of the colon.

Comparison of equipment management and cleaning protocols for rigid sigmoidoscopy.

BACKGROUND: To provide outcome data relating to cleaning of rigid sigmoidoscopy equipment comparing commonly used techniques, allowing a framework for general guidelines for use in clinical practice. METHODS: A total of 104 rigid sigmoidoscopies were performed in the rooms of two colorectal surgeons using standard techniques. A three-way randomization was performed adopting the following variables: enzymatic washing versus steam sterilization of the light head, disposable versus reusable bellows and use with versus without an air filter. Aerosol from each system was collected on agar plates, and review of colony count numbers was performed. RESULTS: Gross faecal contamination of the rigid sigmoidoscope light head did not occur during any of the procedures. One plate grew a single-gram negative colony; all other contaminated plates showed environmental flora only. Reusable bellows in combination with an air filter showed lower mean colony counts (environmental flora) from the pre-procedure cultures as well as from the bellows' cultures. CONCLUSION: Enteric flora in this study was rarely aerosolized, and the use of an air filter may decrease this likelihood even further. There is no advantage in using disposable insufflation bellows when compared with the reusable type, allowing considerable cost saving. Washing the light head between procedures with enzymatic solution is a safe cheap and effective method of decontamination.

[Transsigmoid access for NOTES]. / NOTES über den transsigmoidalen Zugang.

Transsigmoidal access for NOTES operations is not limited by gender and offers an outstanding controllability of the entry point. Practically all anatomical regions of the abdomen are easily accessible. However, it is particularly prone to contamination and leakage and insufficiency of the access mean that it is far more prone to complications than using alternative access points. Currently, only few data are available on the results of animal experiments and differing technical approaches have been employed. Dedicated surgical instruments are required which should be modified according to the well proven transanal endoscopic microsurgery (TEM) set of instruments. In addition, specialized instrumentation (overtubes/trocars) and the use of transanal ultrasound seem to be recommendable.

Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists.

PURPOSE: The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. METHODS: All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. RESULTS: Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. CONCLUSION: This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy.

Injury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma.

Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. Patients with full-thickness penetrating rectal injury over a 10-year period were identified. All underwent DRE and RS before exploration. Injury location was classified as intraperitoneal (IP) or extraperitoneal (EP). Overall sensitivities for DRE and RS were calculated as well as sensitivities for RS in the identification of IP versus EP injuries. Seventy-seven patients were identified. Overall sensitivity for DRE and RS was 51 per cent (95% CI: 37-65%) and 78 per cent (95% CI: 65-92%), respectively. Sensitivity of RS for identification of rectal injury based on anatomic distinction was 58 per cent (95% CI: 30-86%) for IP and 88 per cent (95% CI: 75-100%) for EP injuries. Anatomic location determines the value of preoperative screening tests for identification of penetrating rectal injuries. RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.